Proposed Medicare Advantage changes cannot accurately be called ‘cuts,’ experts said

More than 60 million people rely on Medicare for health coverage, and raising the alarm about potential cuts to the program is a perennial talking point among both Republicans and Democrats. 

On Feb. 6, Sen. Tom Cotton, R-Ark., took a swing at President Joe Biden on Twitter after Biden tweeted that House Republicans were threatening to cut Social Security and Medicare.

"It's President Biden who is proposing to cut Medicare Advantage, a program used by almost 4 in 10 Arkansas seniors," Cotton wrote.

It wasn’t clear from Cotton’s tweet what Biden proposal he was referring to, and his office did not respond to requests for comment. 

• One is a rule change, set to take effect April 3, that’s intended to increase the government’s ability to audit Medicare Advantage plans and recover past overpayments. 

• The other is an annual update that would modify Medicare Advantage’s risk adjustment model, which determines how much the government pays insurers for beneficiaries’ reported health conditions. 

Health care policy experts said it is most likely that Cotton’s tweet was referring to the rule change intended to increase the government's ability to recover overpayments.

The rule change would return billions of dollars to the federal government and is expected to reduce private insurers’ profits, though experts say the reductions will be minimal compared with overall spending. 

Those companies might, in turn, increase enrollees’ out-of-pocket costs or reduce benefits, experts said. But it is unclear if that will happen. 

Meanwhile, the second change — an annual update to the rates paid to Medicare Advantage insurers — will reduce payments to Medicare Advantage insurers. But the reductions will be offset by other program modifications that are expected to yield a 1% increase in Medicare Advantage spending per person in 2024.

A group that lobbies for Medicare Advantage plans sent a memo to lawmakers that said proposed changes would affect 30 million beneficiaries, Politico reported.  

The federal government pays private insurance companies for Medicare Advantage on a per-patient basis, making adjustments to the amounts based on the health of the beneficiary.

The sicker a Medicare Advantage patient is, the more money a private insurer will receive from the federal government to cover the cost of care. Experts said there’s been a longtime concern that Medicare Advantage insurers have a financial incentive to identify preexisting conditions among enrollees.

Auditors from the federal government review medical files to confirm whether patients have the diseases that their private insurers listed, Kaiser Health News reported. These audits showed that private insurers had listed conditions for patients that could not be verified, resulting in millions of dollars of overpayments to Medicare Advantage insurers.  

When overpayments are identified, private insurers must pay back the difference to the federal government.

The administrative rule change that would allow the government to recoup overpayments is a new version of a rule that was proposed in 2018, under the Trump administration. The final rule comes after the government spent years determining how to identify and recover overpayments, experts said.

"The essence of this rule is to set up procedures whereby the Medicare program can recoup the overcharge," said Joseph Antos, a health policy expert at the American Enterprise Institute, a conservative-leaning think tank.

It is estimated that from 2023 through 2032, the federal government will recover $4.7 billion in overpayments from major insurance companies including Humana, UnitedHealthCare and Aetna. That money represents about one-fifth of 1% of federal payments to Medicare Advantage plans during that period, according to Dara Corrigan, director of Medicare’s Center for Program Integrity.

Though the rule change is expected to reduce private health insurance companies’ revenues from Medicare Advantage plans, the U.S. Department of Health and Human Services doesn't consider that to be a "cut." 

"Auditing plans and recouping funds puts money back in the Medicare trust funds when big insurance companies get caught taking advantage of the Medicare program," Kamara Jones, a spokesperson for the department, told PolitiFact. This is about "holding our seniors' health care to the standard they deserve."

The Centers for Medicare & Medicaid Services is also required by law to ensure accurate payments and prevent fraud, waste and abuse. 

Experts said they would not characterize the rule change as a "cut." 

Featured Fact-check

Facebook posts

stated on November 15, 2024 in a photo

Smallpox was “never eradicated, it’s held in check by vaccines,” and RFK Jr. would eliminate coverage for the smallpox vaccine.

The federal government is attempting to avoid paying more than it should, said Paul Ginsburg, a senior fellow at the University of Southern California Schaeffer Center for Health Policy and Economics. "To me, that is simply running the program better and more efficiently to protect the integrity of the federal funds being used for it."

It's difficult to determine whether Medicare Advantage enrollees will feel the rule changes. 

"My read of the evidence is that reductions in payments to Medicare Advantage plans are largely borne by the plans themselves, either through lower profits or cost reductions," said Matthew Fiedler, a senior fellow with the University of Southern California-Brookings Schaeffer Initiative for Health Policy.

A 2022 analysis from Avalere, a health care consulting company, found that the rule change could result in beneficiaries facing higher costs or fewer plan options or benefits.

Because private insurers’ profits will be reduced, companies could pass along those costs to enrollees in small ways, including slight increases in insurance premiums or out-of-pocket costs and, in some cases, fewer benefits, the American Enterprise Institute’s Antos said.

Antos said he did not expect drastic cost increases or benefit reductions that would encourage enrollees to turn to non-Medicare Advantage plans.

Centers for Medicare & Medicaid Services estimated that the other proposed 2024 updates to the way Medicare Advantage insurers will be paid will result in about a 3% reduction in payments to Medicare Advantage insurers in 2024. But the agency said that other modifications to the Medicare Advantage program would offset that reduction and yield a 1% increase in spending per person in 2024.

An insurers’ lobbying group said Centers for Medicare & Medicaid Services did not provide adequate information about how it arrived at the 1% figure. "Consequently, there is no way to validate the accuracy" of that estimate, a spokesperson said.

The proposed 2024 adjustments are not a cut, but are part of "the routine annual process of implementing the law as far as how Medicare Advantage plans are paid," the University of Southern California’s Ginsburg said. 

Cotton said, "It’s President Biden who is proposing to cut Medicare Advantage."

Experts said Cotton likely was referring to a recent rule change that allows the government to recover overpayments to insurers and is expected to reduce insurers’ profits. Those companies might, in turn, raise enrollees’ out-of-pocket costs or reduce benefits. It is unclear whether that will happen. 

Another proposed change, an annual update to the rates paid to Medicare Advantage insurers, will reduce payments to insurers. But reductions will be offset by other changes that are expected to yield a 1% increase in payments to insurers per person in 2024. 

Experts say it’s inaccurate to characterize the changes as a "cut" to Medicare Advantage. We rate it False.

PolitiFact researcher Caryn Baird contributed to this report.

RELATED: Fact-checking Joe Biden's 2023 State of the Union address